VATS lobectomy improves overall survival vs open surgery in early-stage NSCLC

BACKGROUND: Video-assisted thoracoscopic surgery (VATS) is currently the most common approach for pulmonary lobectomy in early-stage lung cancer. Reported advantages include less pain, fewer complications, faster recovery, and improved postoperative quality of life. The widespread adoption of VATS lobectomy is principally based on non-oncological benefits. Its oncological equivalence to open surgery remains assumed as no single trial has been powered for survival. To address this important question, we sought to conduct an individual patient data meta-analysis of eligible randomised trials. METHODS: We systematically reviewed PubMed, MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials, limiting the searches to papers published between Jan 1, 2000, and June 13, 2025. We included completed randomised controlled trials comparing VATS versus open lobectomy performed after the year 2000 conducted for clinical early-stage non-small-cell lung cancer in adults aged 18 years or older that collected information on mortality and disease recurrence. Individual patient data were extracted from the included studies, and authors were contacted where data were unavailable. The primary outcome was overall survival, and the secondary outcome was disease-free survival. Risk of bias was assessed using the Cochrane risk of bias tool for randomised trials. The primary analytical strategy was a one-stage random effects Cox proportional hazards model. A two-stage approach was performed to assess consistency. FINDINGS: We screened 554 articles and three studies were eligible for inclusion. Data were provided for 1185 patients (586 randomised to VATS and 599 randomised to open lobectomy). Overall survival favoured VATS lobectomy, reflecting a 21% mortality risk reduction (pooled hazard ratio [HR] 0·79 [95% CI 0·65-0·96]). Disease-free survival was similar in both groups (pooled HR 0·91 [0·75-1·12]). There was no evidence of statistical heterogeneity across trials for either outcome. INTERPRETATION: This meta-analysis provides evidence that surgical access by VATS lobectomy improved overall survival compared with open surgery without any compromise to disease-free survival. These results underscore the importance of prioritising VATS when technically feasible as the access of choice for surgical resection of early-stage non-small-cell lung cancer. FUNDING: National Institute for Health and Care Research.